CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes with " " and use separate sheet if necessary. 1. CS ID No. (to be filled up by CSC)

I. PERSONAL INFORMATION
2. SURNAME FIRST NAME MIDDLE NAME

S | A | B | R | O | S | O | J | O | S | E | P | H | M | I | M | A | Y | | |

| |

| | / 1985

| |

| |

| |

| | |

| | |

| | |

| | |

| | |

| |

| |

| |

| |

| |

| |

| |

| | |

| | |

| |

| |

| | |

| | |

| | |

| J | O | R | A | M |

|3. NAME | EXTENSION | | (e.g. | Jr., |Sr.) |

| N/A|

4. DATE OF BIRTH (mm/dd/yyyy) 5. PLACE OF BIRTH 6. SEX 7. CIVIL STATUS

05 / 03

16. RESIDENTIAL ADDRESS

BUHI, CAMARINES SUR

Male Single Married Annulled Fem ale

J. P. RIZAL ST., SAN ROQUE, BUHI, CAMARINES SUR

Widowed Separated

ZIP CODE 17. TELEPHONE NO.

4433 (054) 621-00-39

Others, specify ___________ 18. PERMANENT ADDRESS

8. CITIZENSHIP 9. HEIGHT (m) 10. WEIGHT (kg) 11. BLOOD TYPE 12. GSIS ID NO. 13. PAG-IBIG ID NO. 14. PHILHEALTH NO. 15. SSS NO.

FILIPINO 1.62 55 O+ N/A N/A 10-050101545-2 05-0670361-0 N/A N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary) 19. TELEPHONE NO. 20. E-MAIL ADDRESS (if any) 21. CELLPHONE NO. (if any) 22. AGENCY EMPLOYEE NO. 23. TIN ZIP CODE

J. P. RIZAL ST., SAN ROQUE, BUHI, CAMARINES SUR

4433 (054) 621-00-39 mr.sabroso@yahoo.com (0915) 232-05-15 012 944-727-402

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME FIRST NAME MIDDLE NAME OCCUPATION EMPLOYER/BUS. NAME BUSINESS ADDRESS TELEPHONE NO. 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

N/A N/A N/A N/A N/A N/A N/A (DECEASED) N/A N/A N/A N/A (DECEASED)

/ N/A / / N/A / / N/A / / N/A / / N/A / / N/A / / N/A / / N/A / / N/A / / N/A / / N/A / / N/A / / N/A /

26. FATHER'S SURNAME FIRST NAME MIDDLE NAME 27. MOTHER'S MAIDEN NAME SURNAME FIRST NAME MIDDLE NAME

SABROSO RAMON SANTOS EQUIZABAL

MIMAY JOCELYN GOMEZ

N/A N/A
(Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

28. LEVEL NAME OF SCHOOL (Write in full) DEGREE COURSE (Write in full) BASIC EDUCATION CURRICULUM
SECONDARY EDUCATION CURRICULUM

YEAR GRADUATED

(if graduated)

HIGHEST GRADE/ LEVEL/ UNITS EARNED (if not graduated)

INCLUSIVE DATES OF ATTENDANCE From To

SCHOLARSHIP/ ACADEMIC HONORS RECEIVED

ELEMENTARY SECONDARY VOCATIONAL / TRADE COURSE COLLEGE

BUHI NORTH CENTRAL SCHOOL

BICOL UNIVERSITY EARLY AND LATE OPPORTUNITY PROGRAM HIGH SCHOOL

1998 2002 N/A 2007 N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A

JUNE, 1992 JUNE, 1998 N/A JUNE, 2002 N/A N/A N/A

MARCH 27, 1998 APRIL 5, 2002 N/A APRIL 14, 2007 N/A N/A N/A

N/A N/A N/A

Outstanding College Gradute in BSIE major in Electrical Technology and with Academic Distinction

N/A BICOL UNIVERSITY COLLEGE OF INDUSTRIAL TECHNOLOGY N/A

N/A
BS IN INDUSTRIAL EDUCATION

N/A N/A N/A

N/A N/A N/A

Page 1 of 4

GRADUATE STUDIES

N/A N/A

(Continue on separate sheet if necessary)

IV. CIVIL SERVICE ELIGIBILITY

29. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEE RATING DATE OF EXAMINATION / CONFERMENT LICENSE (if applicable) PLACE OF EXAMINATION / CONFERMENT NUMBER DATE OF RELEASE

LICESURE EXAMINATION FOR TEACHERS 77.60 (LET) N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

08/26/2007 N/A N/A N/A N/A N/A N/A

LEGAZPI CITY N/A N/A N/A N/A N/A N/A

0969599 N/A N/A N/A N/A N/A N/A

02/05/2008

N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work)
30. INCLUSIVE DATES (mm/dd/yyyy) From To
CLASSROOM TEACHER/RELIGIOUS AFFAIRS COORDINATOR/FOOTBALL TEAM COACH

POSITION TITLE (Write in full)

DEPARTMENT / AGENCY / OFFICE / COMPANY (Write in full)

MONTHLY SALARY

SALARY GRADE & STEP INCREMENT (Format "00-0")

STATUS OF APPOINTMENT

GOV'T SERVICE (Yes / No)

06 / 01 / 2012 06 / 06 / 2011 03 / 30 / 2012 06 / 07 / 2010 03 / 31 / 2011 06 / 01 / 2009 03 / 31 / 2010

BUHI ST. JOSEPH'S ACADEMY, INC. BUHI ST. JOSEPH'S ACADEMY, INC. BUHI ST. JOSEPH'S ACADEMY, INC. BUHI ST. JOSEPH'S ACADEMY, INC. BUHI ST. JOSEPH'S ACADEMY, INC. N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)

CLASSROOM TEACHER/RELIGIOUS AFFAIRS COORDINATOR/FOOTBALL TEAM COACH

CLASSROOM TEACHER/RELIGIOUS AFFAIRS COORDINATOR/FOOTBALL TEAM MODERATOR

CLASSROOM TEACHER/RELIGIOUS AFFAIRS COORDINATOR

06 / 02 / 2008 03 / 31 / 2009 CLASSROOM TEACHER

PHP 7,928.00 PHP 6,732.00 PHP 6,166.00 PHP 6,032.00 PHP 4,600.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

PERMANENT NO PERMANENT NO
CONTRACTUAL CONTRACTUAL CONTRACTUAL

NO NO NO N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

/N/A / /N/A / /N/A / /N/A / /N/A / /N/A / /N/A / /N/A / /N/A / /N/A / /N/A / /N/A / /N/A / /N/A / /N/A /

/N/A / /N/A / /N/A / /N/A / /N/A / /N/A / /N/A / /N/A / /N/A / /N/A / /N/A / /N/A / /N/A / /N/A / /N/A /

N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

CS FORM 212 (Revised 2005), Page 2 of 4

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

31. NAME & ADDRESS OF ORGANIZATION (Write in full) INCLUSIVE DATES (mm/dd/yyyy) From To NUMBER OF HOURS POSITION / NATURE OF WORK

ANTIOCH COMMUNITY - BUHI (St. Francis of Assisi Parish) BARANGAY COUNCIL FOR THE PROTECTION OF CHILDREN BARANGAY PHYSICAL FITNESS AND SPORTS DEVELOPMENT COUNCIL CADET OFFICERS LEADERSHIP TRAINING; ANISLAG, DARAGA, ALBAY N/A

02 / 27 / 2012 Present 03 / 22 / 2011 Present 03 / 22 / 2011 Present

04 / 15 / 2002 05 / 03 / 2002

N/A N/A N/A N/A N/A

MEMBER PRIVATE SECTOR REPRESENTATIVE PRIVATE SECTOR REPRESENTATIVE ASSISTANT INSTRUCTOR N/A

/ N/A /

/ N/A /

(Continue on separate sheet if necessary)

VII. TRAINING PROGRAMS (Start from the most recent training.)

32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write in full) INCLUSIVE DATES OF ATTENDANCE (mm/dd/yyyy) From To NUMBER OF HOURS CONDUCTED/ SPONSORED BY (Write in full)
PHILIPPINE FOOTBALL FEDERATION AND NAGA CITY- CAMARINES SUR FOOTBALL ASSOCIATION

BASIC REFEREES COURSE ASIAN FOOTBALL CONFEDERATION "C" CERTIFICATE COACHING COURSE IN-SERVICE DEVELOPMENT SEMINAR 3RD LANGUAGE CONGRESS MARIAN YOUTH CONGRESS 2010 MARIAN YOUTH CONGRESS 2009 CONTINUING PROFESSIONAL EDUCATION PROGRAM IN-SERVICE DEVELOPMENT SEMINAR KOLPING YOUTH JOURNEY (CORE FORMATION PROGRAM FOR YOUTH LEADERS) PRACTICE TEACHING 2007 STUDENT TEACHERS' IN-SERVICE TRAINING SEMINAR WORKSHOP ON TEACHING T.L.E.: CONTENT AND CREATIVE STRATEGIES ON - THE JOB - TRAINING 1ST STUDENT GOVERNANCE TRAINING N/A

08 / 26 / 2011 05 / 18 / 2011 04 / 06 / 2011 11 / 05 / 2010 09 / 11 / 2010 09 / 12 / 2009 07 / 26 / 2009 05 / 28 / 2009

08 / 28 / 2011 06 / 01 / 2011 150 04 / 08 / 2011 11 / 05 / 2010 09 / 12 / 2010 09 / 13 / 2009 07 / 26 / 2009 05 / 29 / 2009

N/A

N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

BUHI ST. JOSEPH'S ACADEMY, INC. SCRIPTURE ASSOCIATION OF RINCONADA CACERES YOUTH AND CAMPUS MINITRY CACERES YOUTH AND CAMPUS MINITRY
UNIVERSITY OF SAINT ANTHONY AND BUHI ST. JOSEPH'S ACADEMY, INC.

BUHI ST. JOSEPH'S ACADEMY, INC. KOLPING SOCIETY PHILIPPINES, INC. ILAWOD NATIONAL HIGH SCHOOL TABACO NATIONAL HIGH SCHOOL BICOL UNIVERSITY COLLEGE OF INDUSTRIAL TECHNOLOGY GOODFOUND CEMENT CORPORATION BICOL UNIVERSITY COLLEGE STUDENT COUNCIL N/A N/A

05 / 14 / 2009 05 / 16 / 2009 11 / 27 / 2006

03 / 12 / 2007

02 / 03 / 2007 AND/ 10 / 2007 09 / 13 / 2006 09 / 14 / 2006 04 / 28 / 2005 05 / 31 / 2005 240 10 / 10 / 2003 10 / 12 / 2003

N/A N/A

/ N/A /

/ N/A /

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

33. SPECIAL SKILLS / HOBBIES: 34. NON-ACADEMIC DISTINCTIONS / RECOGNITION: (Write in full) 35. MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full)

PROFESSIONAL DRIVER (RESTRICTION CODE 1,2) MS OFFICE APPLICATIONS LITERATE AND INTERNET PERFORMS ELECTRICAL AND DRAFTING WORK PLAY, COACH, AND REFEREE OF FOOTBALL PLAYING BASKETBALL, BADMINTON

OUTSTANDING COLLEGE STUDENT OF BACHELOR OF SCIENCE IN INDUSTRIAL EDUCATION MAJOR IN ELECTRICAL TECHNOLOGY SCHOOL CERTIFICATION FOR WINNING 2ND PLACE AS COACH OF VALUES EDUCATION III STUDENT FOR BRAIN QUEST DURING THE 2012 A.P.S.C.A. PRIVATE SCHOOLS DAY

BUHI SOCIETY OF FOOTBALL CLUBS KOLPING YOUTH - BUHI ANTIOCH COMMUNITY - BUHI BUHI ST. JOSEPH'S ACADEMY, INC. SCHOOL'S FACULTY CLUB N/A
CS FORM 212 (Revised 2005), Page 3 of 4

N/A N/A N/A

(Continue on separate sheet if necessary)

36. a.

Are you related by consanguinity or affinity to any of the following : Within the third degree (for National Government Employees): appointing authority, recommending authority, chief of office/bureau/department or person who has immediate supervision over you in the Office, Bureau or Department where you will be appointed? Within the fourth degree (for Local Government Employees): appointing authority or recommending authority where you will be appointed? YES NO If YES, give details: _____________________________________ _____________________________________ _____________________________________ YES NO If YES, give details: _____________________________________ _____________________________________ _____________________________________ YES NO If YES, give details: ________________________________ ________________________________ YES NO If YES, give details: ________________________________ ________________________________ YES NO If YES, give details: ________________________________ ________________________________ YES NO If YES, give details: ________________________________ ________________________________ YES NO

b.

37

a. Have you ever been formally charged?

b. Have you ever been guilty of any administrative offense?

38.

Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal?

39.

Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped from the rolls, dismissal, termination, end of term, finished contract, AWOL or phased out, in the public or private sector?

40.

Have you ever been a candidate in a national or local election (except Barangay election)?

If YES, give details: ________________________________ ________________________________

41.

Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA 7277); and (c) Solo Parents Welfare Act of 2000 (RA 8972), please answer the following items: Are you a member of any indigenous group? Are you differently abled? Are you a solo parent? YES NO If YES, please specify: ____________________ YES NO If YES, please specify: ____________________ YES NO If YES, please specify: ____________________

a. b. c.

42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee) NAME ADDRESS TEL. NO.

MR. IRVIN CARLO A. NOBLE MR. DON N. CORRAL MRS. ANITA L. STA. ROSA
43.

SAN ROQUE, BUHI, CAMARINES SUR SAN ISIDRO, BUHI, CAMARINES SUR BUHI ST. JOSEPH'S ACADEMY, INC

(0928) 783-18-39 (0999) 407-35-03

ID picture taken within the last 6 months 3.5 cm. X 4.5 cm (passport size)

(054) 621-12-00
Computer generated or xerox copy of picture is not acceptable

I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust that this information shall remain confidential. 12429156
COMMUNITY TAX CERTIFICATE NO.

PHOTO

SAN PEDRO, BUHI, CAM. SUR

ISSUED AT SIGNATURE (Sign inside the box)

01

/ 04

/ 2012

07/14/2012
DATE ACCOMPLISHED RIGHT THUMBMARK

ISSUED ON (mm/dd/yyyy)

CS FORM 212 (Revised 2005), Page 4 of 4